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Implementation of a multidisciplinary approach to
care for people living with HIV aged over 80 years
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Aging, Comorbidities, Frailty, Polypharmacy for PLWH > 80 Years at Chelsea Westminster London
"integrating comprehensive geriatric assessment into HIV routine care is imperative to identify frailty."
High Proportion of HIV+ People 80 or Older Remain Independent
International Workshop on HIV & Aging 2023, October 26-27, Washington, DC
Reported by Mark Mascolini for NATAP and Academic Medical Education
HIV-positive people 80 or older tended to remain independent despite having a handful of comorbidities, according to results of a 63-person study at London's Chelsea and Westminster Hospital [1]. These four-score-and-older people had a median of 5 comorbidities and took a median of 6 non-HIV drugs.
Continuing aging of the HIV population allows focused study of older and older cohorts. This analysis of people seen in a big London HIV clinic may be the first spotlighting people 80 and older. The Chelsea and Westminster investigators gathered a multidisciplinary team of HIV-specialist pharmacists, geriatricians, and HIV consultants to assess and manage frailty by following the principles of Comprehensive Geriatric Assessment [2]. They used the Rockwood Clinical Frailty Scale (CFS) [3] to assess frailty in the study group. The analysis involved every 80-or-older person with HIV seen in a dedicated HIV/geriatric clinic from December 2022 to July 2023.
The 63 people with HIV had a median age of 82 (interquartile range [IQR] 80 to 86) and 88% were men. Median time since HIV diagnosis stretched to 20.5 years (IQR 16.5 to 29). Everyone had a viral load below 200 copies, and 50 people (79%) had a load below 20 copies.
Median CFS stood at 2 (IQR 2 to 5), indicating fit individuals who exercise or are very active occasionally, for example, seasonally [3]. Sixteen people (25%) had a frailty score above 5, meaning living with mild frailty (for example, needing help with more difficult instrumental activities of daily living). Twenty-two people (35%) needed a walking aid, 14 (22%) reported at least 1 fall during the year, but only 4 (6%) were housebound.
The group had a median of 5 comorbidities (IQR 4 to 7) and took 6 (IQR 5 to 8) comedications for an overall polypharmacy rate of 85%. Hypertension and cardiovascular disease were the most frequent comorbidities. Nineteen people (30%) voiced concerns about their memory, 16 (25%) had nutrition worries, 19 (30%) expressed concern about mood, and 48 (76%) had discussions related to advance care plans.
The multidisciplinary team requested clinical investigations for 32 people (51%), advised a comedication change for 39 (62%), advised antiretroviral switches for 18 (29%), referred 15 people (24%) to other members of the multidisciplinary team, and referred 11 (17%) to other specialists.
The Chelsea and Westminster team concluded that this group of HIV-positive people 80 or older remained fairly independent with a low overall CFS, despite having several comorbidities, taking many comedications, and having a high polypharmacy rate. The researchers noted that this elderly cohort may constitute a self-selected band of hardy survivors as their less resilient contemporaries succumbed to HIV infection and attendant comorbidities. They believe that "integrating comprehensive geriatric assessment into HIV routine care is imperative to identify frailty."
Link to Oral session:
https://www.youtube.com/watch?v=ZnXkvKueeUA
References
1. Varadarajan M, Blackburn S, Girometti N, et al. Implementation of a multidisciplinary approach to care for people living with HIV aged over 80 years. International Workshop on HIV & Aging 2023, October 26-27, Washington, DC. Abstract 4.
2. Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment – a guide for the non-specialist. Int J Clin Pract. 2014;68:290-293. doi: 10.1111/ijcp.12313. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282277/
3. Dalhousie University. Geriatric medicine research. Clinical frailty scale. https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html
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